Evidence Synthesis Table for Delirium - Annotated Bibliography Example

Student Name: Topic: Evidence Synthesis table Course: Tutor: Institution: Date Due: Evidence Synthesis Table P pharmacological and non-pharmacological I interventions C in delirium prevention O in hospitalised adults Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Sidiqqi N., Holt R., Britton A. M & Holmes J. 2009. Interventions for preventing Delirium in Hospitalized Patients. Pp1-43. Academic unit of psychiatry, Leeds university, UK. CDCIG specialized register was searched using the terms delirium or acute confusion, or acute brain failure, or acute brain syndrome, or acute organic psychondrome, or acute brain syndrome, CENTRAL, MEDLINE, EMBASE, psye INFO, CINAHL, SINGLE, ISTP, INSIDE. Patients aged 16 yrs. and over admitted for delirium included. Regular screening of cognitive function or mental state, protocol driven medical review and investigation, medication review, medication, nursing interventions, education of staff members or family. Data extraction form was designed and piloted. Data were then independently extracted by three reviewers NS, RS and AB with disagreement resolved by a consensus process. Data were then sought for every patient randomized to treatment or control group. Outcomes examined included delirium, duration and severity of delirium, behavioral disturbance, and length of admission, physical morbidity, cognitive status and institutionalization at discharge. Standard care was defined as the usual care available on that unit. Incident delirium in the 7 days after surgery was significantly lower in the intervention group with an Odds Ratio (OR) 0.10 [95% Cl. 0.01, 0.89] and relative Risk (RR) of 0.14 [95% Cl. 0.02. 1.06]. Behavioral disturbance in the 1st 7 days after surgery was also lower for intervention group, but the difference failed to reach statistical significance (RR 0.20 [95% Cl. 0.03, 1.56]) There is little evidence from delirium prevention studies to guide clinical practice. There is no trial evidence available on the effectiveness of any other strategies to prevent delirium in hospitalized patients. There is lack of research on delirium prevention. However, there is paucity of high quality published research on delirium prevention. 1B Jackson KC. & Lipman A. G., 2004. Drug therapy for delirium in terminally ill adult patients. Pp. 1-23. Cochrane database for systematic reviews. Pacific university, US. Electronic searches on MEDLINE using phase 1 and 2 of Cochrane sensitive search strategy for RCTs. Other databases included CENTRAL (1966-2003), EMBASE (1980-2003), CINAHL (1982-2003), PSYCHLIT (1974-2003) & PSYCHINFO (1990-2003) Pharmacological agents of benzidiazipines, midazolam, olanzopine, propofol, risperidone and thioridazine. Titles and abstracts were screened by one review author to determine appropriateness for further evaluation. Assessment of potentially relevant studies for inclusion was done. disagreements were resolved by discussions. Then a grade for methodological quality was signed. A data extraction form was designed Higher scores indicate higher quality in the conduct and/or reporting of the trial. Inter-rate reliability of the quality assessment would have been calculated (using the kappa coefficient). 30 patients evaluated met DSM-III-R criteria for delirium and scored 13 or greater on delirium Rating Scale (DRS). Mean karnofsky performance Score at base was 52.3 (SD 21.3, range 10-90). Patients average medical conditions=12 (SD 4.1, range 6-22). 5 patients died within 8 days of protocol initiation, 17 patients lived beyond two weeks protocol initiation while 4 died within7 days of completing protocol. Selection of chlorpromazine versus haloperidol for the treatment of delirium in terminally ill patients is primarily based on anecdote which making medications to be efficacious. The evidence of using pharmacotherapy kin the palliative population is scarce. 1A Overshot R., Karim S. & Burns A., 2009. Cholinesterase inhibitors for Delirium. The Cochrane database of systemic Review. Pp1-14. University of Manchester, Manchester, UK. A literature review search was conducted on CDCIG which included MEDLINE (1966-2005), CENTRAL, (2005), EMBASE (1980-2005), CINAHL (1982-2004), SINGLE (1980-2004/06), Alsip index to theses (1970-2003). Cholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine and tacrine. Orally administered in any dosage or frequency compared with placebo or standard treatment 3which includes nursing care, environmental measures and single doses of anti-psychotic or benzodiazepines for behavioral disturbance. Citation titles and abstracts were studied by two reviewers. Relevant randomized control trial articles were retrieved for assessment. Disagreements were solved by discussions. Data was sought for every patient, analysis of those who competed trial was done separately. Mean change from baseline, standard deviation and number of participants for each treatment group at each assessment was obtained. Primary outcome included; length of delirium, severity of delirium, presence and severity of behavioral symptoms, secondary outcome involved cognition, use of other medications, need for institutionalization, and length of hospital admission, adverse effects and withdrawals. The mean mini mental state examination (MMSE) = 29.15 and 28.85 for treatment of placebo groups. No difference in groups in race. 15/80 patients developed delirium postoperatively; 8(20.5%) in donepezil group, 7(17.1%) in placebo group. RR = 1.20(95% confidence interval 0.48-3.00. z = 0.39, p = 0.69). No difference found between treatment and placebo groups in the duration of delirium. Presents potential adverse outcomes of delirium, which makes it an area worthy of attention. Research on risk factors in developing delirium is fraught with difficulties. IB Lonergan E., Luxenberg J. & Sastre A., 2009. Benzodiazepines for Delirium. pp. 1-13. The Cochrane database of systemic review 2009. John Wiley & Sons Ltd. USA. CDCIG was searched on 26 February 2008 for all years up to December 2005. An electronic search was carried out on the following databases The Cochrane library, MEDLINE, EMBASE, psye INFO, CINAHL and Lilacs and many other ongoing trial databases and other grey literature sources. The following search terms were used; delirium or confusion and benzo or lorazepam or alprazolam or activan or diazepam or valium or chlordiazepam. Treatment with benzodiazepines of any dosage or another drug. Searching and screening of results was done by two reviewers (ETL, JL). Third reviewer resolved the disagreement. Data on adverse effects and dropouts were recorded, present numerical scores were used to assess response to treatment Response to benzodiazepines is influenced by the cause delirium: surgery, infection, stroke, drugs. The character of delirium: hypoactive, hyperactive, dose of drug, duration of treatment and age of the patient. 106 mechanically ventilated medical and surgical intensive care unit patients. Dexmedotine group = 52, average age = 60, lorazepam group = 49, men in dexmedotomiine=58%, lorazepam=45%. Severity of illness measured by Apache scored (p=0.75); 2 duration of time on mechanical ventilation prior enrolment (p=0.18), level of sedation by RASS (p=0.21). 4 admission diagnoses sepsis/acute respiratory distress/syndrome(p=0.78); The findings made at the lower -level evidence are typically unreliable compared to those of higher-level evidence. The lower-level evidence used makes it easy for conclusions to be drawn. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Lonergan E., Brotton AM., & Luxenberg J., 2007. Antipsychotics for delirium. Pp1-19. The Cochrane database of Systemic reviews. Geriatric unit Royal Prince Alfred Hospital, Sydney, Australia. Identification of trials from a search of the CDCIG on 7 august 2006 using the search terms haloperidol, olanzipine, or zyprexa or aminotriazole, or ability or sertindole or leponex or zeldox or ziprasidone. The databases were; CENTRAL (2006), MEDLINE (1966-2006), EMBASE 91980-2006), psye INFO (1887-2006/02), CINAHL (1982-2006), SIGLE (1980-2004). Treatment with haloperodol, chlorpromazine,risperidone, olanzipine, or quetiapine of any dosage. Searching and screening by two reviewers (ETL, JL). The third review help to resolve disagreements. The reviewers selected trials for relevance and against defined inclusion criteria. Data was sought from every patient irrespective of compliance. Data on adverse effects were recorded, length of hospital stay was also recorded and numerical scores used to assess response to treatment. Outcomes measured were; response to treatment by delirium as measured by the RR as applied by investigators. Incidence of adverse effects, withdrawal from treatment, length of hospital stay, incidence of mortality Only 3 controlled studies found. Patient average age=39.2+/-8.8 yrs-79+/-6 yrs. Female patients=23-80%. Haloperidol was given by injection from 2.5 mg-10 mg/day in the 1st 7 days study. In the 2nd 7-day study; haloperidol, 0.75 mg/day by mouth; dosage was increased daily depending on the state of delirium. 3rd study compared haloperidol 1.5 mg per day by mouth with placebo. No evidence of a differential effect of low dose haloperidol on the overall control of delirium compared with atypical antipsychotics that were reviewed. Joins and expands recommendations made by other students made on the same subject. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Bourne RS. Tahir TA., Borthwick M., & Sampson EL., 2008. Drug treatment of delirium. Pp. 1-10. University hospital of wales, Cardiff, UK. A literature search was performed using MEDLINE (1966-2005), EMBASE (1980-2005), CINAHL (1982-2005), and Cochrane Central Register Of Controlled Trials (2005). The search strategy included delirium, confusion, hospitalization and patient. Included both prospective and retrospective clinical trials. A randomized controlled trial of 175 senile dementia patients with delirium was conducted. It was compared with haloperidol and olanzapine against control treatment. Research articles were identified and several reviews conducted. The articles were systematically retrieved from databases mentioned. Case reports and conference articles were also reviewed. A significant proportion of patients suffer from hypoactive delirium i.e. although not agitated and restless, they can still experience unpleasant psychiatric symptoms like delusions. 84 papers were identified containing retrospective reports. 199 participants were identified. These were from 51 papers while the 33 retrospective studies involved 1880 patients. Many studies had methodological failings. There was evidence of lack of randomization making it difficult to control potential cofounders like comorbidity. Inadequate blinding and concealment of allocation to study groups leading to potential bias. A summary of the prospective studies of the drug treatment or prevention of delirium is included. 2/3 of the prospective studies identified were published within the last 5 years. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Dahlke S. & Phinney A., 2008. Caring for hospitalized adults: The silent, Unspoken piece of Nursing Practice. 34: 6, 41-48. Journal of Gerontological Nursing. A qualitative study of interviewing nurses who worked in mid-sized regional hospital in western Canada. Sampling of 12 RNs on medical or surgical units, both of which admitted large proportions of elderly patients. Nurses ages were from 32 to 61 av. 48 yrs., with an average of 18.5 years job experience Nurses spoke at length during 1.5 hrs. Interview describing how they managed patients. 1.5 hours consumed in interviewing nurses. Open ended questions to elicit stories of nurses’ clinical practice, following up with more specific questions. Approaches used in caring for nurses were described as taking a quick look, keeping an eye on the patients and situation control. The nurses reported using a variety of strategies to assess, prevent, and manage delirium in older adults. There are important socio-cultural and institutional factors that help account for why delirium continues to be problem. Some nurses paid more attention to subtle cues of delirium and looked for possible causes. Nurses identified the paradox that to work in the health care system they needed to be efficient. The nurses described a care environment that did not consider the unique needs of the older adults. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Kemper J. A., (2002). Pain management of Older Adults After Discharge from Outpatient Surgery. Vol. 3 pp. 141-153 Washington university medical center, US. The pain Experience Interview (PEI), a structured scripted interview was used to collect data from participants by telephone. A sample recruited from two mid-western Metropolitan hospital-based outpatient surgery department that performed approx. 16500-5300 outpatient surgery on annual basis. The inclusion criteria for the patients were those older than 60 years with planned discharge of 23 hours. Three experts in the field of pain management reviewed the PEI for content validity and the tool was field tested on five older individuals (65-85) years old for comprehension and ability to answer the questions over the telephone. After approval from the hospitals’ institutional review boards, participants were recruited and each given a copy of PEI enlarged to a size 14 font. They were to record pain medication taken and pain intensity for 3 days after discharge. Pain caused substantial interference on the patients. Standard deviation= 6.6 Pain intensity for the last 24 hours were obtained for worst, least, average and now. It decreased from first morning to the third evening worst pain on postoperative day was experienced by 66% of the participants. The findings indicate a lack of understanding of the role and importance of analgesics and pain relief in assisting the body to return to its optimal functioning an as possible. 1A Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Robinson S., Vollmer C. & Rich C., (2007). Aging and Delirium: Too much or Too Little Pain medication? SIU School of Medicine, Springfield, Illinois, US. A descriptive study conducted in a 500-bed mid-western U.S hospital. A retrospective Review of records of 100 patients who developed delirium during hospitalization. Inclusion criteria was designed Examination of characteristics of both medical and surgical patients who developed delirium during hospitalization in relation to pain management. Attention was given to the amount of medication received in 24hr before the onset of delirium. Demographic data received from the chart included age, primary diagnosis, and Charlton cormobodity score. Each record reviewed for presence of major risk factors for delirium presence on admission. Most of the 100 patients who developed delirium were adults. As twice as many men as women developed delirium. Mean age of those who developed delirium was 76.71 years, range=41.90, average cormobodity=2.22; range=0.9. Average risk factors= 2.26 with the most common being the vision impairment. 39 patients had hearing problems, 39 having comobordity impairment. 31 cases were noted on the night shift and 23 cases of delirium occurred and percentage received r=0.269; p= 0.007. It was difficult to receive files where the physicians had identified delirium as a diagnosis. It was a descriptive study and could not develop any association delirium and pain. However, it revealed that patients with pain who develop delirium had received only a fraction of pain medication. 1A Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Edvardsson D., (2008). Therapeutic Environments for Older Adults: Constituents And Meaning. Vol. 34; Pp. 32-43. Journal of Gerontological studies. Included data collection of between 2001 and 2004 from patients (n = 41), significant others (n = 20) and health care staff (n = 51),in a hospice setting, geriatric setting and an oncology setting. The sampling technique included maximal variation and convenience sampling. A total of 46 interviews were performed. Participant observation was also carried out to describe the aesthetics; of and interactions within setting. Four steps of narrative interview were carried out. First an open reading of the data as a whole to grasp the content and gain a sense of what the texts were about. Second was reading of the texts through and systematically dividing into units. Third was analysis of units for shared content and abstracted into categories, conceptually labeled to capture the content. Then Fourth, interpretation of categorized texts in light of the theoretical frameworks. Creating a homelike environment can positively affect interaction and behavior and lessen confusion and anxiety in individuals with dementia. Physical environment interact with the characteristics and behavior of the people to create overall environment. Average hospice participants = 8 Mean geriatric participants = 9.2 Mean medical part = 11 Average of oncological participants= 9 Indicate the types of participants with their observations and experience to establish physical environment and its relationship to dementia. Findings are majorly personal observations and experience which are subjected to biasness. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Lacasse H., Perreault MM & Williamson DR., 2006. Systemic Review of Antipsychotics for the treatment of Hospital-Associated Delirium in Medically or surgically ill patients. Pp1-8 Prospective randomized, controlled trials comparing the clinical effects of antipsychotics therapy with placebo or comparing 2 antipsychotics treatment in an acute care setting. Data resources included MEDLINE, current contents, cumulative index of nursing and Allied Health Literature, psye INFO, biological abstracts, Cochrane Central register of Controlled Trials and EMBASE database log up to 2006. Variety of delirium scales was used to evaluate clinical efficacy of the 4 trials involved in this study. Multicomponent interventions (excluding pharmacotherapy) were used in the prevention of delirium in hospitalized older patients. .selection of trials was done. Three reviewers independently assessed trial qualities using an adapted evaluation tool and data extracted for evaluation. Reviewers were blinded to each other’s evaluation. Outcomes related to both efficacy and safety were collected. The outcome suggested that antipsychotic agents, either atypical or typical are effective when compared with baseline for the treatment of delirium in medically or surgically ill patients without underlying cognitive disorders. A total of 27 studies were identified. 23 were excluded due to lack of control group and randomization, retrospective nature, psychotic agitation or brain injured population. 244 patients were included for in the study and monitored for delirium onset. 30 patients developed delirium as assessed by score above threshold (≥13) on the DRS and meeting DSM-III-R criteria. Patients in the amisulpride and quetiapine groups were given a mean daily dose of 156.4+/_ 97.5 mg/day (range 50-800) and 113+/_85.5 mg. day (range 50-300) All selected studies had small sample sizes of and were likely not powered to detect significant differences between agent hence limiting conclusions that could be drawn. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Hu RF, Jiang XY, Chen JM, Zeng ZY, Chen XY, & Li Y., 2010. Non-pharmacological interventions for sleep promotion in the intensive care unit. Cochrane database of systemic review, issue 11. Art. No. CD 0088. Fuhjan Medical University, Fuzhou, China. Electronic search of Cochrane Central Register For Controlled trials, MEDLINE (1950), EMBASE (1966-present), CINAHL (1982-present), CAM on PubMed (1966-present), AMED (!985), psye INFO (!(^&-Present) Any pharmacological intervention capable of improving sleep. Psychological interventions, environmental, social support, equipment modification, aromatherapy, herbs and physical therapy interventions. .two authors (HRE, CXY) independently examined the titles and abstracts identified from the search. Relevant studies were retrieved and their eligibility assessed according to exclusion and inclusion criteria. 3rd author resolved the disagreement. Two authors HRF and JXY independently extracted data using tool developed by authors. Changes in objective sleep variables as measured by polysmnography, actigraphy or bispectral index including sleep efficiency index (SEI), REM sleep time. The grade approach was used to determine the quality of a body of evidence based on the extent to which one can be confident that an estimate of effect or association reflects the item being assessed. A meta-analysis using a fixed-effect model was performed. 95% Cl. for dichotomous outcome was calculated. Mean difference and 95% Cl. for continuous outcomes was calculated. Not enough evidence provided to demonstrate the efficacy of the application. Sufficient description of data extraction procedures is made. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Milisen K., Braes T., Foreman MD., 2004. Multicomponent strategies for managing delirium in hospitalized plder people: systemic review, katholieke university Leuven, Belgium. A comprehensive search undertaken in all major databases involving Cochrane library, Medline, cumulative index for nursing and Allied Health Literature and Invert. Multicomponent intervention of prevention Vs. treatment. Tested intervention to prevent the development of delirium, whereas the remaining other tested interventions focused on early treatment. Studies were identified from the databases using a two-step strategy by (JL) to identify relevant studies. They were the screened by (KM & JL) to determine if they met inclusion criteria. Data was then collected using specifically designed tools. Characteristics of intervention programs were identified and categorized according to their approach. That the only intervention strategies to prevent the development of delirium are efficacious in reducing the incidence of delirium and nurses should pay a key role in implementing these strategies. The literature search resulted in 19 studies. 7 fulfilled the inclusion criteria; 3 RCTs, 3 controlled st9udies, and one before –after study. In the efficacy of the intervention strategies, 2/4 studies measuring the incidence of delirium in the intervention group, relative reduction = 40% & 36% respectively. 5 studies assessed the severity of delirium, 1 study showed a statistical improvement in functional status of patients. Multicomponent interventions are most effective in preventing delirium and should be implemented through synergic cooperation between the various health care disciplines. Does not test intervention on larger scale hence the need for further investigations. Also the contribution of each element remains unidentified. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Holroyed-Leduc JM., Khandwala F. & Sink KM., 2010. How can delirium best be prevented and managed in older patients in hospital? Canadian medical association, Canada. An electronic search of MEDLINE database (using Ovid) from 1950-2007, EMBASE (1980-2007). The search strategies included the terms delirium, confusion, aged older 65 or older, hospitalized and in-patient. The search utilized Cochrane randomized controlled filter, and systemic review filter. Multicomponent interventions using 3 trials interventions for the prevention of delirium. Two trials used the confusion Assessment Method to diagnosis delirium. There were also 5 trials of pharmacological interventions. English-language articles that addressed the prevention or management of delirium among adults aged 65yrs or older in hospitals. Additional studies by searching the bibliographies of retrieved articles. The importance of adhering to various preventive strategies in the multicomponent interventions should be highlighted and considered when trying to implement these strategies into everyday clinical practice. Citations = 408; MEDLINE = 92, EMBASE = 316, Full text article citations = 56. Multicomponent intervention appeared to be more effective in preventing delirium; Hip fracture: RR 0.75, 95% Cl. 0.64-0.88; P for heterogeneity = 0.58. Two studies reported on mortality. One found a significant decrease in hospital mortality (0.65 [1/155] in the intervention group v. 5.5% [9/164] in control group p=0.03. No relevant outcome data only protocol description. Details were not well documented. There was evidence of multicomponent interventions reducing medical complications. It provided evidence of delirium prevention. 1B Complete Citation, incl. Funding & country of study Research Design Sample Intervention Agent (dose, amount) Procedure (frequency) Outcome Definition Results [reported by group; provide actual values (mean, median, standard deviation, effect size, etc.) for each study group] Study Limitations Strengths Evidence Strength and Quality Milisen K., Braes T., Foreman MD., 2004. Multicomponent strategies for managing delirium in hospitalized older people: systemic review, Katholieke university Leuven, Belgium. A comprehensive search undertaken in all major databases involving Cochrane library, Medline, cumulative index for nursing and Allied Health Literature and Invert. Multicomponent intervention of prevention Vs. treatment. Tested intervention to prevent the development of delirium, whereas the remaining other tested interventions focused on early treatment. Studies were identified from the databases using a two-step strategy by (JL) to identify relevant studies. They were the screened by (KM & JL) to determine if they met inclusion criteria. Data was then collected using specifically designed tools. Characteristics of intervention programs were identified and categorized according to their approach. That the only intervention strategies to prevent the development of delirium are efficacious in reducing the incidence of delirium and nurses should pay a key role in implementing these strategies. The literature search resulted in 19 studies. 7 fulfilled the inclusion criteria; 3 RCTs, 3 controlled st9udies, and one before –after study. In the efficacy of the intervention strategies, 2/4 studies measuring the incidence of delirium in the intervention group, relative reduction = 40% & 36% respectively. 5 studies assessed the severity of delirium, 1 study showed a statistical improvement in functional status of patients. Multicomponent interventions are most effective in preventing delirium and should be implemented through synergic cooperation between the various health care disciplines. Does not test intervention on larger scale hence the need for further investigations. Also the contribution of each element remains unidentified. 1B References Dahlke S. & Phinney A., 2008. Caring for hospitalized adults: The silent, Unspoken piece of Nursing Practice. 34: 6, 41-48. Journal of Gerontological Nursing. Edvardsson D., (2008). Therapeutic Environments for Older Adults: Constituents And Meaning. Vol. 34; Pp. 32-43. Journal of Gerontological studies. Ellen F., Mazurek B.,Stillwell B. S., Kathleen M., & Williamson., 2010. Critical appraisal of the evidence: Part III. Pp. 43-51. Ganong’s H.L., (1987). Integrative interviews of Nursing research. 10; 1-11 Journal of Gerontological Nursing. Holroyed-Leduc JM., Khandwala F. & Sink KM., 2010. How can delirium best be prevented and managed in older patients in hospital? Canqadian medical association, Canada. Hu RF, Jiang XY, Chen JM, Zeng ZY, Chen XY, & Li Y., 2010. Non-pharmacological interventions for sleep promotion in the intensive care unit. Cochrane database of systemic review, issue 11. Art. No. CD 0088. Fuhjan Medical University, Fuzhou, China Kemper J. A., (2002). Pain management of Older Adults After Discharge from Outpatient Surgery. Vol. 3 pp. 141-153 Washington university medical center, US. Lacasse H., Perreault MM & Williamson DR., 2006. Systemic Review of Antipsychotics for the treatment of Hospital-Associated Delirium in Medically or surgically ill patients. Pp1-8 Melnyk B. &Overholt, (2005). Evidence-Practiced in Nursing & Health: A guide to Best Practice. Williams & Wilkins, U.S Milisen K., Braes T., Foreman MD., 2004. Multicomponent strategies for managing delirium in hospitalized plder people: systemic review, katholieke university Leuven, Belgium Robinson S., Vollmer C. & Rich C., (2007). Aging and Delirium: Too much or Too Little Pain medication? SIU School of Medicine, Springfield, Illinois, US. Sparbel J. H. & Anderson A. M., (2000). Integrated Literature Review of continuity of Care: Part 1, Conceptual Issues. 32:1 Pp.17-24. Sigma Theta Tau International Read More